AAA repair and colonic ischemia in a 60 year-old man. On POD 2 he c/o increased abdominal pain and he passes some guaic positive stool.
Me: Is there any other pertinent historical information? No problems with the surgery?JF: The history is as I told you. The patient is otherwise fine, extubated, alert.Me: Then I would proceed with physical exam, listen to breath and heart sounds, concentrating on abdominal exam.JF: He has a low-grade temp, heart and lung sounds are fine; on abdominal exam he has bowel sounds, some mild to moderate tenderness in the LLQ.Me: I want to do a rigid sigmoidoscopy.JF: You see several patchy areas of erythema and duskiness in the sigmoid colon.Me: It sounds to me like you're not describing full thickness necrosis of the bowel wall. At this time I want to get a CBC; I would start a second-generation cephalosporin and attempt to manage this non-operatively, with serial abdominal exams, CBC's and close observation.JF: On the second day the pt c/o ongoing abdominal pain, low grade fever and he passes some more guaic positive stool.Me: And his physical exam?JF: He still has LLQ tenderness.Me: If it the same, or better, I would continue antibiotics and treat him expectantly.JF: Let's say the tenderness is slightly worse.Me: Then I would take him to the OR for ex lap.JF: On ex lap you see that the sigmoid colon is somewhat dusky.Me: I would do a sigmoid colectomy with an end colostomy and Hartman's pouch.JF: On this pt with low-grade fever and a fresh AAA repair, do you want to examine the graft?Me: Yes. [Thinking] No. In fact, I would make an effort not to disturb the aneurysm sac with a fresh graft in it, since I am doing a contaminated case.